I used to get upset when the call was for an old fall or fall yesterday or fall last night. The same when I’d get called for abdominal pain and a person says they have been having the pain for two weeks or three months. I got upset because the nature of the call was not acute. When many think of EMS, they think of us responding to sudden emergencies. We think this way most of the time, as well. Not an acute emergency, why are you bothering us? So the pain is not new, why didn’t you call when it happened? Two weeks, really, never thought to go to the ED before now? But think about this: assuming their levels of pain are the same, who do you think more of? The man with pain who sucks it up for a week until he can’t take it anymore or the man who calls 911 after only 15 minutes of pain.

The question I always try to get answered is why did you call now?

The answer is usually one of two.

A. The pain kept getting worse until the point where I just could not take it anymore
B. I ran out of pain medicine, and now is a convenient time for me to get to the hospital and get some more pills

I am all for treating pain, but when it comes to nonacute pain, it gets less easy.
Here is how I handled each of these two scenarios in recent weeks.

A. Patient has had abdominal pain for three days. He is at home watching the football game. He is wearing a New York Giant hat and wearing a New York Giant t-shirt. There is a plastic waste basket by the couch side that the patient has been vomiting into. On TV the Giants are locked in a tight game with their opponent. The man lives three blocks from the ED.

B. The woman was in a car accident a week ago. They gave her Ultram at the hospital and Ultram does nothing for her. She hurts all over. She usually takes Percocet for her back pain, but she has been out for several days. She says can’t take the pain anymore. She lives three blocks from the hospital. When we arrive, she has her coat on and is locking her front door.

Both said they were 10 of 10 on the pain scale.

I gave patient A 100 mcgs of Fentanyl and 4 mg of Zofran. I treated Patient B’s pain by getting her as comfortable on the stretcher as possible, fluffing her pillow, talking courteously to her and using “distraction therapy for pain management.”

Patient A I believed was in true agony, and was only calling because he truly couldn’t take it. Patient B seemed more like getting her Percocet renewed was just another item on her list of things to do for the day.

I always wonder if I did right.

Patient A ended up in a hospital bed in a room with a TV set where he fortunately got to see his Giants come back to win the game.

Patient B ended up in the waiting room.

Sometimes I wish pain management were simpler. I wish there wasn’t so much controlled substances paperwork and the need to exchange kits after every use, and so many cautions about possible drug seekers or excess concern about side effects, and just plain judgment. I wish that other caregivers wouldn’t say, “You gave them how much!” And I wouldn’t have to always explain the patient is stable and still in pain, and likely needs more. I wish that for every patient who said they were in pain, we could just turn on pain medicine like oxygen and let it flow.

9 Comments

Early on, someone told me this: our job is to treat people. If I give controlled substances to one person who is not really in that much pain or not really having a seizure, that is much better than withholding it from someone who really needs it. That stuck with me. Too many people are caught up in guarding the “goodies” from those they feel aren’t worth it. The energy would be much better spent trying to relieve pain!

I have been criticized for giving too much pain control. I take that as a sign that I am giving more than the average medic, which is both encouraging and dissapointing at the same time. Side note: somehow these “excessive” doses of pain control have never caused an adverse reaction such as the always feared respiratory depression.

“Pain is what the patient says it is.”
This is what nurses are taught. As a Paramedic you are constantly lectured not to be too liberal with your narcotics because “you don’t want to trigger a DEA investigation.” Yes, I really was told that.
The heart of the matter is that you treat your patient, and treat them with dignity and respect, which can be difficult sometimes. Especially when you are pretty sure they are seeking drugs. Did your LOL seem comfortable with the distraction therapy? Sometimes with a patient that has chronic pain, they are so used to the pain, that they may be able to act in a manner that we consider normal, but still be in that subjective 10/10 pain.
That is another point that we need to remember. Pain is subjective. We TRY to make it objective by allowing our patients to rate it on a number scale, but it is objective. What may be 10/10 diaphoretic producing pain to me, may only be 3/10 pain to you.
One last point to consider…If you have a drug seeking patient, you are not the one that caused the problem, and you probably are not the one that is going to fix it either. Treat the patient how you feel best fits the situation and then bring your suspicions up to the Doc and ER staff (if the patient isn’t a known seeker). They have a lot more resources than you do. (or they may opt to wash their hands of the patient as well because they don’t have the time, money, room, energy what have you either)
I agree with you though, pain management should be simpler.
For the record, I would listen to the lecture, walk away and treat my patients they way I felt they needed to be treated. The lectures? Always came from my supervisors, never my Med Director or the ER Doc I handed my patients to.

Thanks for the comment, ambgirl. I will be posting next week about our new patient controlled analgesia guidleine where the medic asks the patient if they want pain medicine, or more pain medicine (provided they meet certain criteria.) I always feel better when i give the meds, than when I don’t.

In most cases, the amount of pain control that you are going to give them is an amount they are already tolerant to if they are a true drug seeker.
During clinicals, I had a patient who was on long term narcotics for a shoulder disease, he dislocated his shoulder (intentionally or not I am not completely sure). We ended up giving him 50mg of morphine (yes fifty) and 10mg of versed and he still wasn’t relaxed enough to reduce the shoulder. (It was then easily remedied by giving him propofol and easily reducing it) I would love to give him the benefit of the doubt that he wasn’t dislocating his shoulder strictly for the drugs, but who knows.

On the other side of things, I had a patient with a known history of drug seeking behavior and low tolerance for pain. He had a diagnosed PE and I was transferring him to tertiary care. My transport orders were for 2mg of morphine every 30 minutes for a 45 minute transport. This man was easily 300 pounds and opioid tolerant. No wonder he was in pain the entire way. I called for further orders and got two more milligrams.
Some doctors are so scared of giving pain control, I think this is just as bad. I think a push needs to be made to utilize weight based dosing for morphine and fentanyl. Sure 2mg of morphine will do great things for a 50kg old lady. It sure isn’t going to do much for myself at 100kg and young.

The protocols I work under (Iowa state protocols) are starting to get it better. As guidelines, we can give 4mg doses of morphine every 5 minutes or up to 100mcg of fentanyl. Along with this, we can give up to 2.5mg of Versed or Valium.

I like the benzo/narcotic combo. We discussed it briefly, but the docs felt it qualified as concious sedation. I’ll bring up the Iowa protocol next time. That will help. thanks again for the great comment.

In most cases, the amount of pain control that you are going to give them is an amount they are already tolerant to if they are a true drug seeker.
During clinicals, I had a patient who was on long term narcotics for an orthopedic disease and presented with a dislocated shoulder (intentionally or not I am not completely sure). We ended up giving him 50mg of morphine (yes fifty) and 10mg of versed and he still wasn’t relaxed enough to reduce the shoulder. (It was then easily remedied by giving him propofol and reducing it) I would love to give him the benefit of the doubt that he wasn’t dislocating his shoulder strictly for the drugs, but who knows.
On the other side of things, I had a patient with a known history of drug seeking behavior. He had a diagnosed PE and I was transferring him to tertiary care. My transport orders were for 2mg of morphine every 30 minutes for an hour transport. This man was easily 300 pounds and opioid tolerant. No wonder he was in pain the entire way. I called for further orders and got two more milligrams.
Some doctors are so scared of giving pain control, I think this is just as bad. I think a push needs to be made to utilize weight based dosing for morphine and fentanyl. Sure 2mg of morphine will do great things for a 50kg old lady. It sure isn’t going to do much for myself at 100kg and young.
The protocols I work under are starting to get it better. As guidelines, we can give 4mg doses of morphine every 5 minutes or up to 100mcg of fentanyl. Along with this, we can give up to 2.5mg of Versed or Valium for severe pain.

This is long, sorry…I’m not going to tell you what to do, but I thought I’d mention what I do. I have some basic rules about pain, First no matter how improbable it seems, if you say you have pain, and my service or I haven’t responded to you before, I believe you implicitly and treat you within protocols, Second if we have responded to you before, I joke and play and remind you that were beginning to know each other, then I begin to treat you within protocols and while en-route get a thorough history of your pain, right before we get to the hospital, I tell you to talk to the ER doc about getting a referral to a pain management clinic. As time goes on, and I respond to you more frequently, I keep that friendly banter going, talk to you about life, and how hard it is to live with chronic pain, start trying to get you to understand that you and a doctor who specializes in pain management need to sit down and develop a reasonable treatment plan. Now that were friends, I jokingly remind you I’m not a drug dealer on wheels, if I was, I’d have more bling on. And then I treat your pain within protocols. The vast majority of the time this works, and works well. I don’t get complaints, and I have a little army of the nicest, the trashiest, the craziest people in the world who think that Paramedics are the best thing since sliced bread. Like the guys above said, if this patient is truly a drug seeker/drug addict, our little 2-4 of MS and 50-100mcg of Fentanyl isn’t going to do much. The respect we show though, goes a long way. I have patients that when I walk in the door, say “oh hell it’s you”, you gonna lecture me again. To which I reply “yup” and then in front of the entire family as we do an assessment and get Vitals I kindly remind the patient that the meds are hard on his liver and kidneys, that if he doesn’t find a better way he’s gonna end up at Dialysis 3 times a week and in liver failure, and that if I get an urgent call while I’m messing with him, he had better make room on the cot, because I’m not letting some kid die today…You’d be, hell even I’m surprised at how well this joking banter works, and it gives me the chance to educate the patient and the family. At least half the time they say “wait are you the only ambulance on?” to which I reply “yup, in this area at least, next one will come from 10 miles further”…some people just don’t know

Cat CampYou gave her 20 Milligrams?!!I never even knew EMS could give a "transporting patient" any pain meds at all. Guess you can tell Ive Never (Thank God) had to be transorted in a rescue before. That is until recently, Jan 8, 2018. I slipped and dislocated my shoulder!!! The Pain was unbearable!! I pray I never experience that pain…
2018-02-10 09:08:03

Barbara WrightAngry Snowman: Naloxone RefusalsBIG CITY MEDIC, amazing how you tear down the attempts of someone trying to save a life at the time or the future. I would have fought for the user to go to the hospital. Big City Medic would lead me to believe you are becoming big city hardened
2018-02-06 19:45:34

NateNaloxone in Cardiac Arrest"What drug do you give?" is a trick question. In cardiac arrest of any cause, the one proven benefit to survival is CPR. Good CPR is a rarity. Most is middling. Second, in VF/VT arrest, the only thing that changes is defibrillation, after good CPR. The rest of ACLS has a paucity of data. It's…
2018-02-05 04:35:24

JordanMother and SonDrug overdoses are normally the ones you get back. So always especially difficult when you don’t. Only a recently qualified Paramedic and haven’t had to deliver bad news as of yet. Dreading the day I do.
2018-01-25 13:45:09